Kalorm does not look like someone who’s going to imminently wake up! He’s still in slow-wave deep sleep, the most relaxed and restful-looking sleep he’s had all day; the current dose of painkillers and other drugs must be working well, because his heart rate is a beautiful 55 bpm (still with the marked sinus arrhythmia of a very fit person with good parasympathetic nervous system tone) and his blood pressure is a comfy 110/60. 

His breath volumes are decreasing a bit, after over an hour of immobility, but he’s oxygenating beautifully, and his lung sounds are decreased at the bases but not yet especially crackly with secretions.

Also Halthis is still there, giving a thorough report to Kerrin, the medtech taking over for the next 6 hour block. She’s pretty tired, but still interested in meeting Merrin and sharing impressions about their patient. 

(She is, in fact, incredibly excited to meet Merrin, whose work on this case - and in general - is pretty impressive! She has been counseled by Personnel not to emphasize this, which is sort of weird but okay.)

Kerrin, her relief for the next evening-night shift, has been with her since eight, watching their patient sleep and receiving a mostly-subvocalized report to avoid disturbing him. 

She's a rank 6 medtech, and unusual in a couple of ways, though not the same ways that Merrin is unusual. For one, she's forty-nine, and while her stamina is less than it was in her twenties – she used to be one of the few ICU medtechs who regularly worked eight hour shifts – she more than makes up for it with all her years of experience. Medical technology changes regularly, of course, but she's still entirely able to keep up. She doesn't have as many emergency sim hours as Merrin at 23, and in fact mostly doesn't do "weird" emergency sims at all, but she has nearly ten times as many accumulated hours of real life emergency experience. 

Two, she doesn't seem to mind moving, and in fact, has kept doing it most of her life, two years here, three years there, accumulating ICU and related experience in nearly all of the major-city hospitals on the planet. She's never worked for Exception Handling, but has a breadth and variety of experience that's rare outside of it. She's also done hospital coordinator work at three different small, relatively resource-constrained regional hospitals. 

Three, she's someone whose circadian rhythm is happiest at night. It's been relatively true her whole life, but actually moreso in her forties. Midnight-6 am is her favorite shift block, but she'll pick up an 8 pm-2 am without complaint, and a 2 am-8 am tomorrow night if they want. 

Four, perhaps unsurprising for someone with more than thirty years of experience in ICU medicine, she is basically impossible to faze. Her colleagues have described her as 'aggressively calm' and her default facial expression as 'resting boredface'. 

Five, she heard about the case - she participates in some of the Treatment Planning markets during her off-shift time - and proactively reached out to Personnel about it. She's happy to be here. 

Personnel is planning ahead! Merrin's performance metrics show that she functions best on 12h day shifts that start between 7 and 9 am, so an 8 am-8 pm is nearly the perfect zone for her.

She's unlikely to be rested enough to start a 12h day shift at 8 am tomorrow, given what she's been doing to her circadian rhythm and the fact that she is, if necessary, definitely going to park herself here for the next 6 hours if it takes that long for Kalorm to get off the ventilator. (Though Personnel has put a note on the staffing section that whoever takes over has to make sure Merrin leaves at 2 am to get some rest for tomorrow; if he's not ready to be extubated by then, one he should probably at that point stop trying and also get a proper night's sleep, and two, it'll mean they're in the long tail of less fortunate worlds where Something Went Wrong and it might be another day.)

The plan is to have Tharrim on tomorrow's 8 am-2 pm again, and hopefully a nice and well-rested Merrin back for the 2 pm-8 pm. Halthis is tentatively hopeful that she can stay up a little late and then sleep in with the help of some circadian-rhythm-shifting drugs, and push her sleep cycle forward enough to cover tomorrow's 8 pm-2 am. They're still sifting through dossiers and updating the staffing markets with performance incentive offers for todays 2 am-8 am, but once they pick someone, they'll have Merrin plus, hopefully, a total of four other medtechs who know Kalorm, have developed some rapport with him, and are willing to mostly focus on this case for the next week or two. 

Here comes Merrin! She's in such a good mood! She cannot wait to tell Kalorm how amazingly he's doing. (Too bad he's asleep, but she is completely behind the plan of letting him sleep as long as he needs.) 

aaaaah she forgot the part where she was going to have to meet new people who she doesn't know and who are probably way smarter than her Merrin is in a cheerful enough mood (and still somewhat disinhibited from exhaustion) that the habitual voice of social awkwardness only whispers and slides past her. 

Also her name rhymes with the evening-night shift medtech's. Great. Now she's definitely going to keep intrusively noticing that. 

...Kalorm looks so comfortable. Did what'shername – Halthis, that was the evening shift medtech – get him set up like that??? Merrin wants to learn the secret wizardry of making a patient look that comfortable on the FLOOR!!! 

She smiles at both of the other medtechs, glances at Kalorm sleeping, and then subvocalizes rather than greeting them out loud. [Uh, I'm Merrin]

Oh wow, they have floor chairs, and there's an extra for her! That's so considerate. She sits down in it. It's surprisingly comfortable, yay. 

[It sounds like he had a pretty good day?] 

Halthis glances over at Kerrin. 

[I'll give you the quick version right now. I already went through it in more depth with Kerrin, she can fill you in on details. During Tharrim's shift, I think he was still metabolizing the sedation, and finding a lot of his symptoms - and treatments - frustrating, but having a difficult and exhausting time communicating his needs. In particular I think the dialysis is unpleasant for him; he managed to express that the sound bothered him a lot, so he might be having sensory sensitivities, but also a lot of people just find it unsettling having their blood going through a machine, and it's - well, a particularly blatant reminder of his condition. Anyway, he got very frustrated and didn't manage to finish the run on Tharrim's shift, so his electrolytes were still abnormal, magnesium especially was way high and getting higher. I figured I should try to do some of the communication work from our side, at least make it easier for him to answer yes-or-no questions and have them be the right questions, so I went through everything and asked Diagnostics for a ranked list of likely symptoms...] 

Halthis is SO SMART. Merrin is in AWE. 

(.....Merrin is apparently DEEPLY miscalibrated on which of them is the better medtech is very herself. Halthis is going to go with that.) 

She goes through her shift, in a haphazard mix of chronological and organ-system order. Kalorm's mental status seems to have improved even over the course of her six hours, both with the lower baseline pain medication dosing and likely also his normalized electrolyte levels once she convinced him to try the dialysis and see if normal magnesium would meant less nausea, which she at that point suspected was bothering him more than pain. (He did great on the second try at dialysis, and his kidney function continues to improve; the Diagnostic markets are extrapolating the trend and put 85% that he'll need at most one more treatment and 30% that his kidneys will recover enough overnight that he won't need any.) He communicates effectively with hand signals when he wants turning and suctioning, and she even got him to accept proper mouth care, promising it would help with the nausea. He's still very uncoordinated, but noticeably stronger after the successful dialysis, so likely high magnesium was contributing to muscle weakness. 

His circulatory system is in great shape; he's young, fit and previously healthy, and the short-term cardiac dysfunction seems basically resolved, though they're still trying to keep his heart rate controlled and his systolic blood pressure below 130. She's been using the beta blockers a lot, but she and the markets are in agreement, >95% odds his episodes of faster heart rate or spiking blood pressure are due to pain and anxiety rather than an underlying heart issue. 

Breathing-wise: he wasn't doing incredibly well when she took over, because he refused repositioning at all for most of the morning, not ideal for lung field expansion and drainage, and then he only agreed to lie on his right side and Thallim ended up having to go way up on his O2 concentration. (Halthis can confirm that she thinks she got to the bottom of that; he was uncomfortable on his left side because his hip is sore or something, she asked Diagnostics to look into potential causes and they didn't see anything obvious on the scans and suspect bruising and soft tissue injury, but if it worsens or just fails to improve tonight they'll do more tests.) Anyway, the combination of successful dialysis, and a few rounds of alveolar-recruitment pressure cycles on the ventilator, have really helped. He did over an hour on minimum settings before this, and he was tired enough to want a break afterward, but still oxygenating fine. She really feels like he'll be ready on the next try. 

Unfortunately his gut is showing no sign of improving, and the nausea is bothering him a lot. They tried a new anti-nausea drug to specifically address the side effects of his bolus pain medication, and it seems to have made the situation a little better, but ultimately his body and brain are receiving a lot of loud signals that something is badly wrong, and practically everything is a trigger for him, apparently including the lung-recruitment ventilator mode, he did not have a good time with it on the last round. Well. It was effective, she cleared out some stickier gobs of mucus that she suspects were plugging various minor bronchioles, but she had to suction him more aggressively for it, and after suctioning him and doing mouth care and turning him all in less than five minutes before that, it was just too many things, and set off some vomiting. He must have no tone in his pyloric sphincter, since he's refluxing bile back into his stomach constantly. With that, combined with gastric juices that also aren't going anywhere (she sent it for analysis a few times to check the mix, visually it's just...green stuff...), they drained 400 ml on her shift and 300 ml on Tharrim's shift. 

No sign of an upper GI bleed, at least, and scans look clear for a lower GI bleed; it seems unlikely, he's been hemodynamically stable and he admits to abdominal discomfort but it doesn't seem to be among the top three things bothering him. For now they're trying a new drug that is in theory supposed to prevent his damaged stomach and overstimulated gag reflex from actually getting signals through and setting off the neurological pathway for vomiting, and he'll have fewer potential triggers once the tube is out. Though if he does vomit, he's still at pretty high risk of aspirating, they'll need to monitor that carefully. In the longer run - tomorrow afternoon, maybe - if he hasn't popped a GI bleed on them and if the motility-increasing drugs continue to do basically nothing, they really need to do something more directly about the feces currently occupying his unmoving colon. He did not exactly conveniently do bowel prep for them before having a life-threatening accident, and letting it sit there will risk something turning into an actual obstruction, not to mention unnecessary discomfort for the patient. 

What else... She's done some passive range-of-motion exercises with him, he seemed to like it except for the sore hip. She suspects he has some peripheral neuropathy in his feet that's bothering him, and some stretching helped. She also got the full set of pillows she likes to use for patients in his general position, namely, "skinny guys with limited mobility and a lot of painful body parts"; they're over there and she loaded the slideshow of different pillow arrangements for Merrin to refer to. 

So, on the one hand, Halthis is GREAT and so smart and Merrin is so impressed! That is so many things to get done in a six-hour shift. Merrin never feels like she can get anything done in a six-hour shift, she spends the whole time trying to catch up on market updates. 

On the other hand: Halthis is very smart and this is very much a smart person report and today Merrin is, despite the revitalizing effects of a massage and cold water dip, a TIRED Merrin. Who is having trouble assimilating all of that information right now. It's not the first - or the hundredth - time that she's felt that way, but you would THINK that after she had Kalorm for more than thirty hours over two days, she would be up to speed and not feel like an idiot while she's getting handover. 

Merrin nonetheless tries very hard to smile and nod along and ask sensible questions. 

Kerrin also listens intently, despite the fact that she presumably just spent twenty minutes receiving an even more detailed report, and goes so far as to type up some extra notes on her own console. She types terrifyingly fast.

Oh no there are TWO medtechs in the room with her who are way smarter and better at things than her Merrin blinks and tries not to look as stupid as she feels.

[So, uh, the plan for tonight is - let him wake up when he wakes up, explain the new anti-nausea drug, and get him to do another cycle of the alveolar recruitment protocol before the minimum settings trial?]

Merrin does not like the lung-recruitment mode. Patients would always give her such a confused worried look when she hit START, no matter how thoroughly she tried to explain the way it would feel weird, and also it makes a bad noise though it's not as bad as stupid superheated high frequency ventilation. 

Kerrin has the Treatment Planning: Respiratory section up on two of her screens.

(Merrin will notice that she full-sizes like a dozen more data fields rather than having them in summary mode or hidden entirely, which Merrin ends up having to do just to reduce overwhelm.) 

[Actually they have multiple potential suggestions] she subvocalizes back. [And tests they'd ideally want to run. That's on top of the earlier intervention - when it looked like we'd opened up some blocked lung areas and his volumes were the highest they'd been, Treatment Planning had Halthis administer some nebulized surfactant and a mucolytic blend to help break up the thicker secretions.]

She looks faintly impressed. [Two new drugs! They keep inventing better ones. Anyway, there's some followup to that which might work better with him cooperating, and a number of other measures to combine. They wanted your input] 

(Why does Treatment Planning want Merrin's input?????????? She is not one of the top world experts on lungs!!! They probably have at least twenty of those advising and contributing to the markets!!!!) 

Merrin isn't actually saying anything, but Khemeth - still watching closely, still confused, not sure how much of his inability to put together the hazy pieces is because he's still too tired to especially want to get out of bed - nonetheless immediately recognizes the expression that Merrin tries to hide. 

Message to Personnel: relay to Kerrin or Halthis that they should emphasize Merrin's rapport with Kalorm. She's been the most successful at motivating him to engage with treatments in order to recover faster. 

Halthis didn't actually notice any reaction from Merrin, but she was already pre-emptively wincing; she hadn't thought to say anything to Kerrin about working with Merrin, and really hopes someone else did. 

[You know him better than either of us] she subvocalizes to Merrin. [We need to juggle optimizing his lung function with not tiring him out too much, and of course most of the options will work better with his enthusiastic cooperation, if we can get that. Treatment Planning thinks you have the best implicit model of what he'll find exhausting or frustrating.] 

Merrin nods. [...I guess that makes sense. I'd want to, um, talk to him about it, once he's awake. But he's really motivated to be able to breathe on his own – I mean, I would be too – so I think as long as we can explain why something is going to help, he'd be willing to give it a try?]

Kerrin nods, looking faintly satisfied. [I was hoping that was the case. Our main priority is to help clear secretions and then get his lung fields fully re-expanded. One of the more effective options would be to do another full bronchoscopy and washout and directly administer the surfactant mix to his lower airways, but it would require sedation, which isn't ideal...] 

Their other options include: a vibrating vest that provides chest wall therapy to knock loose stubborn secretions. It's not usually recommended for patients with traumatic injuries, but in Kalorm's case the markets think it's very very unlikely to make anything worse, it'll just hurt. (Which he apparently may not mind, if it otherwise achieves a goal he cares about.) It works best combined with postural lung drainage, which would be MUCH EASIER if he were in a BED with the usual positioning assistance; on the floor, they can't feasibly position him facedown. For awake, mobile patients, they can use a massage-table-like contraption, but getting Kalorm onto that won't be easy or comfortable, especially while he still has the breathing tube to wrangle.

It might still be worth trying the vest without the full set position changes, but in that case they'll want to get as much help as they can from inhaled nebulized mucous-loosening drugs. With Kalorm's cooperation, they could combine that with deep breathing lung-expansion exercises for 10-15 minutes and get pretty good coverage. The only reason they wouldn’t make this a first-line option is because the most effective mucolytic drug mix can cause nausea; it was fine when he was sedated, but he may prefer not to risk it while awake.

There are some other options, mostly variations on assisted coughing or chest therapy to knock secretions loose. Overall they’re more convenient and less uncomfortable than the vest, but probably less effective. 

Merrin frowns, looking thoughtful. 

[I’m actually tempted to ask him about doing the bronchoscopy without sedation, or with only a little bit. It’s probably the most effective option we have, and it’s fastest, right? And doesn’t actually require moving him around as much, either. I wouldn’t want to put most people through that, but - I think he might prefer it to taking half an hour before he can even start the minimum settings trial]

Kerrin looks VERY DUBIOUS but nods. Merrin is, after all, the Kalorm expert. 

Merrin is still thinking. 

[I do think he'd agree to us putting him back in the bed temporarily, if it's for a specific exercise. I actually think that sort of challenge is good for him. It'd be tiring, though, it might take longer for him to recover from it than it would for mild sedation to wear off. And, I mean, we can still do that kind of respiratory therapy with him later once he's off the ventilator, when it's less of an enormous hassle. ...I'd want to run both options past him, just, I think he's going to be pretty motivated to do whatever gets this over with soonest] 

Halthis glances between them. 

(Meeting Merrin in the flesh is...interesting. It keeps feeling like everything Merrin says is slightly surprising, slightly not-matching-her-expectations, and yet it's weirdly hard to pin down what doesn't match. Halthis has, at this point, watched quite a lot of footage of Merrin's previous work with Kalorm, and she can't pin down any specific discrepancy, it's just - it feels like there's something she must not have entirely understood.) 

...Also she is in fact very tired, she's been here coming on seven hours, so possibly her brain is just not working at full capacity. 

[I think that's just about everything we needed to cover? I did tell Kerrin some things about how he prefers to be positioned and which mouth care supplies are most comfortable for him, but I can't exactly demonstrate while he's asleep, so I don't think it makes sense to explain it to you separately] 

Merrin is officially a very stupid person, because she has no idea what alternate mouth care supplies Halthis could possibly be referring to not productive right now. 

[That makes sense. I'm, uh, not really here for a medtech shift anyway] since her brain is still very tired, making her even stupider than usual. [I think that's covered all the context I actually need for, um, just explaining to him what the plan is and what his options are]

Kerrin nods. [We can take over from here] 

She'll go, then, still feeling faintly confused and curious but it's really not a priority to resolve right now. 

Aaaaaaaaaand now it's just her and Kerrin. Who is intimidating. According to Merrin's brain, it would be fine if Kalorm were awake right now for her to interact with, but since he isn't, it's instead AWKWARD.